1013459700 NPI number — TARA L BRODKIN MD PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013459700 NPI number — TARA L BRODKIN MD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TARA L BRODKIN MD PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013459700
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 64568
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85082-4568
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-424-4008
Provider Business Mailing Address Fax Number:
855-230-1466

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9070 E DESERT COVE AVE
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
SCOTTSDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85260-6227
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-860-2322
Provider Business Practice Location Address Fax Number:
480-860-2433
Provider Enumeration Date:
11/10/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BRODKIN-GAUER
Authorized Official First Name:
TARA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MEMBER MANAGER
Authorized Official Telephone Number:
480-860-2322

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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